وضعیت افسردگی به عنوان پیش بینی ترک موفقیت در یک مطالعه اثربخشی در دنیای واقعی از درمان جایگزینی نیکوتین

To provide population-level evidence of the role of current depression on smoking cessation treatment success, we conducted a secondary analysis of data obtained from a large cessation study conducted in over 13,000 smokers. On the basis of self-reported history of depression diagnoses at baseline, participants were divided into four mutually exclusive groups: current/recent depression, recurrent depression, past depression and no depression history. Cessation outcomes were compared among the four groups at 6-month follow-up. Of the 6261 individuals who were consented and attempted to be contacted for follow-up, 4648 (74.2%) had no diagnostic history of depression, 591 (9.4%) had a past history of depression, 759 (12.1%) had a current/recent depression diagnoses, and 263 (4.2%) had recurrent depression (both current and history). Those with recurrent depression were significantly less likely to quit smoking compared to those with no history of depression. In unadjusted analyses, recurrent depression was associated with significantly lower odds of quitting compared to those with either no history or a past history of depression. Current/recent depression was also associated with poorer quit outcomes compared to those with no history of depression. Depressed smokers may benefit from more individualized, in-person approaches to smoking cessation.

Smoking is the number one cause of preventable death and disease with approximately five million attributable deaths per year worldwide (WHO, 2009). It is projected that by 2030, 8.3 million deaths per year will be tobacco-related (Mathers and Loncar, 2006). While over 40% of smokers in the United States attempt to quit each year, less than 9% are successful for 3 months or longer; this decreases further to less than 6% among those with low levels of income and education (NCI, 2010), and those with co-morbid depressive illness are even less likely to successfully quit (Glassman et al., 1990). A significant proportion of smokers have co-occurring mental health disorders (Lasser et al., 2000). Approximately 30% of individuals with mental health disorders are daily smokers (Grant et al., 2004). Individuals with a history of mental illness are more likely to initiate smoking (Rohde et al., 2003), are approximately twice as likely to smoke, and be more severely tobacco dependent (Farrell et al., 2001 and John et al., 2004). One of the most common mental health conditions among smokers is a current or past history of depression with approximately 60% of individuals with a history of depression either current or past smokers (Lasser et al., 2000). It is not known whether smoking initiation occurs prior to or follows the onset of depressive symptoms; however, genetics research points to a shared etiology (Tsuang et al., 2012). Individuals with a past history of depression are more likely to progress to daily smoking (John et al., 2004) and a history of daily smoking has also been shown to significantly increase the risk of major depression (Breslau et al., 1998). As well, depression has been cited as the most common antecedent prior to relapse during smoking cessation (Shiffman, 1982). In a recent systematic review and meta-analysis of smoking cessation trials and depression (Gierisch et al., 2012), 16 unique RCTs were identified in the literature, but only three recruited participants with current depression and many of the identified papers were of subgroup analyses of study subjects with a positive history of depression. One of the key questions the authors of this review attempted to address was “Are there differential effects of smoking cessation strategies by depression status (i.e. history positive vs. current depression)?” They identified only two studies with sufficient information. One study did not show any difference in outcome by depression status (Evins et al., 2008) and the other study showed that mood management information improved cessation rates in history positive smokers but not currently depressed smokers (Munoz et al., 1997). A recent study (Piper et al., 2010) with over 1500 smokers participating in a clinical trial showed that internalizing disorders (i.e., anxiety and mood disorders) were related to poorer cessation outcomes after 8 weeks of pharmacotherapy and behavioral counseling but did not predict abstinence at 6 months. Most treatment intervention studies exclude those with current depression and the few that have included participants with current depression typically have small sample sizes (Hall et al., 2006, Vickers et al., 2009 and MacPherson et al., 2010). As such, there is a paucity of empirical evidence of the effect of current depression on smoking cessation in treatment intervention studies. This study is one of the only ones to examine this on a large-scale. The sample in the present study is representative of the smoker population in Ontario interested in making a quit attempt (Reid et al., 2014) and as such includes individuals with psychiatric diagnoses including depression, thus allowing for the evaluation of the real-world effect of depression diagnoses on smoking cessation treatment outcomes using Nicotine Replacement Therapy (NRT). The objective of the current study was to examine whether current, recurrent or past depression differentially impacts quit rates using data collected from a large population-based sample of over 6000 smokers motivated to quit who called in to a toll-free number to receive a 5-week supply of NRT through the mail. The overall outcomes of this study have been reported previously (Zawertailo et al., 2013). This paper reports on the findings from a secondary analysis of the data where we hypothesized that a current diagnosis of depression (with or without a history of past depressive episodes) would be a strong and significant predictor of abstinence at 6-month follow-up.

3.1. Sample characteristics Demographic characteristics and smoking behavior of the study participants are presented in Table 1. The majority of study participants were female, with a mean age of 44 years. More than two-thirds (68.2%) of the sample smoked more than 20 cigarettes per day at baseline and the majority had a moderate (47.6%) or high (42.0%) level of nicotine dependence. Table 1. Characteristics of the baseline and 6-month follow-up samples. Baseline sample(n=6261) a Respondents(n=2601) a Lost to follow-up(n=3660) a p-Value b Demographic characteristics Age (years), mean (S.D.) 43.5 (12.5) 46.1 (12.4) 41.6 (12.2) <0.001 Sex (female), % (n) 58.5 (3665) 62.4 (1623) 55.8 (2042) <0.001 Educational level, % (n) 0.787 Less than high school diploma 26.5 (1652) 26.1 (677) 26.7 (975) High school diploma 30.0 (1873) 29.9 (776) 30.1 (1097) Post-secondary 43.6 (2720) 44.0 (1143) 43.2 (1577) Household income, % (n) 0.019 ≤$20,000 29.5 (1740) 29.1 (707) 29.7 (1033) $20,001–40,000 28.1 (1656) 26.3 (640) 29.3 (1016) $40,000–80,000 30.8 (1818) 32.8 (797) 29.4 (1021) >$80,000 11.7 (689) 11.8 (286) 11.6 (403) Smoking characteristics Heavy smoking (20+cigarettes/day), % (n) 68.2 (4271) 67.6 (1757) 68.7 (2514) 0.341 Confidence in ability to quit, mean (S.D.) 7.6 (1.9) 7.6 (2.0) 7.7 (1.9) 0.018 HSI score, % (n) 0.137 Low 10.4 (650) 11.3 (293) 9.8 (357) Moderate 47.6 (2981) 46.8 (1217) 48.2 (1764) High 42.0 (2630) 41.9 (1091) 42.0 (1539) Number of previous quit attempts, % (n) <0.001 0 6.8 (423) 6.3 (164) 7.1 (259) 1–5 68.7 (4301) 65.9 (1713) 70.7 (2588) 6+ 24.5 (1537) 27.8 (724) 22.2 (813) Past quit methods or aids used, % (n) Nicotine replacement therapy (patch/gum/inhaler) 54.5 (3415) 57.4 (1494) 52.5 (1921) <0.001 Bupropion 27.8 (1738) 29.9 (777) 26.3 (961) 0.002 Counseling (individual or group) 5.8 (361) 6.9 (180) 4.9 (181) <0.001 Acupuncture/hypnosis/herbal remedies 16.8 (1049) 20.1 (524) 14.3 (525) <0.001 Self-help materials 16.0 (1002) 18.0 (467) 14.6 (535) <0.001 Psychiatric history & substance use Depression, % (n) 0.002 Recurrent 4.2 (263) 5.1 (132) 3.6 (131) Current/recent 12.1 (759) 13.1 (340) 11.4 (419) Past 9.4 (591) 9.8 (255) 9.2 (336) No history 74.2 (4648) 72.0 (1874) 75.8 (2774) Anxiety, % (n) 0.017 Recurrent 3.5 (218) 4.1 (107) 3.0 (111) Current/recent 9.0 (563) 9.8 (255) 8.4 (308) Past 6.8 (425) 7.0 (182) 6.6 (243) No history 80.7 (5055) 79.1 (2057) 81.9 (2998) Other psychiatric disorder(s), % (n) c 0.695 Recurrent or current/recent 3.7 (229) 3.8 (98) 3.6 (131) No history 96.3 (6032) 96.2 (2503) 96.4 (3529) Alcohol consumption (number of drinks on typical day drinking), % (n) <0.001 0 23.2 (1420) 24.0 (612) 22.6 (808) 1–2 30.7 (1881) 34.8 (885) 27.9 (996) 3–5 30.6 (1873) 28.6 (728) 32.0 (1145) 6+ 15.4 (945) 12.6 (320) 17.5 (625) Substance use (past 30 days), % (n) d 12.8 (803) 12.6 (328) 13.0 (475) 0.668 Note: HSI=Heaviness of Smoking Index. a Sample sizes vary due to missing data on some variables. b P-value for the difference between respondents and those lost to follow-up; χ2 test of association or t-test. c Other psychiatric conditions included schizophrenia, bipolar disorder, and personality disorders. No participant had a past history only of these disorders. d Marijuana, cocaine, sedatives, opiates, stimulants and other drugs. Table options Baseline characteristics of those with and without complete 6-month follow-up interview data are presented in Table 1. Several significant differences emerged between those who completed follow-up interviews and those who did not; however, many of these differences were small in magnitude but statistically significant given the large sample size. Compared to those lost to follow-up, participants who completed the 6-month follow-up interview were older, had lower confidence in ability to quit, and were more likely to be women, have higher incomes, have a history of anxiety and depression, have made a greater number of previous quit attempts in the past, have previously used various quit aids, and were less likely to be heavy alcohol users. Participants (n=6261) were divided into four mutually exclusive groups based on self-reported diagnostic history of depression at baseline: recurrent depression (4.2%, n=263), current/recent depression only (12.1%, n=759), past depression only (9.4%, n=591), and no history of depression (74.2%, n=4648). Demographic characteristics and smoking behavior of the study participants according to depression group are presented in Table 2. Participants with a recent and/or past diagnosis of depression were significantly more likely to be female than those with no history of diagnosis, and were also more likely to have a household income less than $20,000/year. Participants with a recent and/or past diagnosis of depression were also more likely to report smoking 20 or more cigarettes/day and to be classified as having a high level of nicotine dependence. Confidence in ability to quit smoking was lower among those with a recent or past history of depression, compared to those with no history. Those with recurrent depression more often reported having attempted to quit six or more times in the past, and were less likely to not have made a previous quit attempt. Participants with a recent and/or past diagnosis of depression were more likely to have tried each of the different cessation methods. Those with a recent or past history of depression were much more likely to report experiencing recent or past anxiety, reflecting their high rate of comorbidity; only 7.8% of those with no history of depression had a recent or past history of anxiety. Participants with current/recent depression were more likely to report a current/recent diagnosis of schizophrenia, bipolar disorder, or personality disorder. Those with a diagnosis of depression were more likely to abstain from alcohol compared to those with no history of depression, but were more likely to report use of other substances such as marijuana, cocaine, sedatives, opiates, or stimulants in the past 30 days; recent substance use was highest among those with recurrent depression. Table 2. Baseline demographic and smoking characteristics of participants according to history of depression diagnosis. Recurrent depression(n=263) a Current/recent depression(n=759) a Past depression(n=591) a No history of depression(n=4648) a p-Value b Demographic characteristics Age (years), mean (S.D.) 44.50 (11.37) 44.27 (11.69) 43.94 (12.10) 43.21 (12.71) 0.052 Sex (female), % (n) 70.7 (186) 71.7 (544) 70.6 (417) 54.2 (2518) <0.001 Educational level, % (n) Less than high school diploma 30.0 (79) 29.3 (222) 27.8 (164) 25.6 (1187) 0.093 High school diploma 29.3 (77) 26.2 (198) 29.2 (172) 30.8 (1426) Post-secondary 40.7 (107) 44.5 (337) 43.0 (253) 43.6 (2023) Household income, % (n) ≤$20,000 50.0 (123) 42.9 (307) 39.6 (224) 24.8 (1086) <0.001 $20,001–40,000 22.8 (56) 27.1 (194) 26.1 (148) 28.7 (1258) $40,000–80,000 21.1 (52) 23.9 (171) 27.2 (154) 32.9 (1441) >$80,000 6.1 (15) 6.0 (43) 7.1 (40) 13.5 (591) Smoking characteristics Heavy smoking (20+ cigarettes/day), % (n) 71.9 (189) 72.5 (550) 70.1 (414) 67.1 (3118) 0.009 Confidence in ability to quit, mean (S.D.) 7.22 (2.10)1 7.38 (2.05)1 7.50 (1.91)1 7.71 (1.85)2 <0.001 HSI score, % (n) Low 5.7 (15) 5.5 (42) 8.3 (49) 11.7 (544) <0.001 Moderate 39.2 (103) 44.0 (334) 43.7 (258) 49.2 (2286) High 55.1 (145) 50.5 (383) 48.1 (284) 39.1 (1818) Number of previous quit attempts, % (n) 0 3.4 (9) 6.7 (51) 8.1 (48) 6.8 (315) <0.001 1–5 62.7 (165) 67.6 (513) 63.8 (377) 69.8 (3246) 6+ 33.8 (89) 25.7 (195) 28.1 (166) 23.4 (1087) Past quit methods or aids used, % (n) Nicotine replacement therapy (patch/gum/inhaler) 62.4 (164) 57.6 (437) 56.3 (333) 53.4 (2481) 0.006 Bupropion 35.0 (92) 29.4 (223) 30.6 (181) 26.7 (1242) 0.005 Counseling individual/group 8.7 (23) 9.6 (73) 8.8 (52) 4.6 (213) <0.001 Acupuncture/hypnosis/herbal remedies 22.1 (58) 19.5 (148) 17.8 (105) 15.9 (738) 0.006 Self-help materials 22.4 (59) 20.7 (157) 20.0 (118) 14.4 (668) <0.001 Psychiatric history & substance use Anxiety, % (n) Recurrent 50.6 (133) 2.4 (18) 3.0 (18) 1.1 (49) <0.001 Current/recent 5.7 (15) 46.5 (353) 5.4 (32) 3.5 (163) Past 4.9 (13) 2.8 (21) 40.9 (242) 3.2 (149) No history 38.8 (102) 48.4 (367) 50.6 (299) 92.2 (4287) Other psychiatric disorder(s), % (n) c Recurrent or current/recent 14.4 (38) 14.8 (112) 2.4 (14) 1.4 (65) <0.001 No history 85.6 (225) 85.2 (647) 97.6 (577) 98.6 (4583) Alcohol consumption (number of drinks on typical day drinking), % (n) 0 29.7 (76) 30.6 (226) 28.1 (162) 21.0 (956) <0.001 1–2 29.3 (75) 29.1 (215) 28.6 (165) 31.4 (1426) 3–5 25.8 (66) 23.6 (174) 27.4 (158) 32.4 (1475) 6+ 15.2 (39) 16.7 (123) 15.9 (92) 15.2 (691) Substance use (past 30 days), % (n) d 31.2 (82) 15.4 (117) 16.2 (96) 10.9 (508) <0.001 Note: HSI=Heaviness of Smoking Index. Means in the same row not followed by the same subscript number significantly differ at p<0.05 level based on Tukey׳s HSD post-hoc comparisons. a Sample sizes vary due to missing data. b χ2 test of association or ANOVA. c Other psychiatric conditions included schizophrenia, bipolar disorder, and personality disorders. d Marijuana, cocaine, sedatives, opiates, stimulants and other drugs.